LEAVE OF ABSENCE FORM

Application Form for Leave of Absence Please write legibly. Date of Filing: ______________________ Applicant’s Name: _____________________________________________________ Surname First Name Middle Name Position: _____________________________________ Salary: _____________________________________ Office: ________________________________________________________________________ Type of Leave: ( ) Sick ( ) Vacation Inclusive Dates: _______________________________ Number of Days: _______________________________ __________________________ Signature Over Printed Name